Urgent-start peritoneal dialysis

INTRODUCTION — Urgent-start peritoneal dialysis (PD) is the term used to describe the practice of initiating PD soon after PD catheter placement among patients with newly discovered end-stage kidney disease (ESKD). Urgent-start PD is useful because it circumvents the need for temporary hemodialysis. Since more than 50 percent of all new dialysis patients do not have a dialysis plan when diagnosed with ESKD, urgent-start PD may increase the number of patients who utilize PD for kidney replacement therapy since it provides PD as a modality option from the start.

The practice of urgent-start dialysis requires developments of protocols, policies, and procedures to help implement the approach in a timely, efficient, and safe method.

This review discusses an approach to urgent-start PD. The use of PD in patients with acute kidney injury (AKI), different types of PD, and PD dosing are discussed elsewhere:

●(See "Use of peritoneal dialysis (PD) for the treatment of acute kidney injury (AKI) in adults".)

●(See "Evaluating patients for chronic peritoneal dialysis and selection of modality".)

●(See "Prescribing peritoneal dialysis".)

DEFINITION — We define urgent-start peritoneal dialysis (PD) as initiation of PD in patients with newly diagnosed end-stage kidney disease who are not yet on dialysis and who require dialysis initiation less than two weeks (as little as 24 to 48 hours) after PD catheter placement but do not require emergent dialysis. Indications for emergent dialysis include hyperkalemia, volume overload, or marked uremia (see 'Contraindications' below). Urgent-start PD is generally reserved for patients who have no plan for dialysis modality but are considered good candidates for PD.

Our definition of urgent-start PD is widely but not universally used. As an example, some investigators reserve the term "urgent-start PD" to PD started within 72 hours of PD catheter insertion and use the term "early-start PD" for PD started between 72 hours and 14 days after catheter insertion [1].

BACKGROUND — Peritoneal dialysis (PD) is a type of dialysis that patients typically perform at home, after the patient (and/or caregiver) receives appropriate training. Occasionally, PD may be temporarily performed in a dialysis center to assist a patient who is unable to perform dialysis at home due to temporary disability or lack of adequate support at home (respite PD) or to provide dialysis to a patient who has not yet completed PD training.

PD provides short- and long-term clinical outcomes that match or exceed in-center hemodialysis (see "Dialysis modality and patient outcome"). PD also provides patients with several lifestyle advantages that are not provided by hemodialysis and is less costly to the health care system [2,3]. (See "Dialysis modality and patient outcome", section on 'Selection of dialysis modality'.)

Despite these advantages, in the United States at least, PD is infrequently offered to patients who require urgent initiation of dialysis. Such patients are usually started on hemodialysis using a temporary hemodialysis catheter. This is because most centers have established inpatient and outpatient protocols for performing acute or semi-acute hemodialysis but not for performing urgent PD. As an example, most hospitals/medical centers have a committed and expert surgical or interventional radiology/nephrology staff that can place vascular catheters (which are often required for acute hemodialysis) within 24 hours. Most hospitals have access to a well-trained nursing staff that can provide hemodialysis quickly and safely.

By contrast, there are few medical centers that have committed staff available for the placement of peritoneal catheters semiurgently (ie, within 24 to 48 hours). In addition, few hospitals have committed nursing staff with expertise in PD. Many outpatient PD clinics do not have expertise in starting patients on PD urgently.

In addition, it is conventional practice to avoid using the peritoneal catheter for two to four weeks after placement in order to minimize pericatheter leaks or dysfunction. Although many reports suggest that it is possible to use catheters before two weeks, experience doing so is limited [4-9].

As a result, PD is traditionally offered only to patients who have been closely followed by a nephrologist and sufficiently informed about dialysis options prior to needing dialysis. In addition to being sufficiently informed to choose PD, patients need to be trained to perform PD, which takes approximately two weeks of instruction. As a result, it is challenging to initiate PD in patients who present with advanced chronic kidney disease and require urgent dialysis.

The difficulty in initiating urgent PD has contributed to the low utilization of PD [2]. It has also increased the utilization of temporary vascular catheters, which are associated with a high risk of infection and a higher mortality rate compared with fistulas or grafts [10,11]. The vast majority of all predialysis patients in the United States start in-center hemodialysis with a central venous catheter as their initial dialysis access [12]. (See "Tunneled hemodialysis catheter-related bloodstream infection (CRBSI): Management and prevention", section on 'Administer antibiotic lock therapy'.)

For selected patients, urgent-start PD can obviate the need for temporary hemodialysis before starting long-term PD. This has numerous potential benefits, including avoidance of temporary hemodialysis catheters [13]. In addition, urgent-start PD may increase the overall utilization of PD.

OUTCOMES — Observational data suggest that urgent-start PD has a similar or lower risk of mortality compared with urgent-start hemodialysis [14-19]. In a propensity-matched observational study including over 1400 patients, urgent-start PD was associated with a 24 percent reduction in hospitalizations compared with initiation of hemodialysis with a central venous catheter [20].

Patients treated with urgent-start PD also may have fewer short-term, dialysis-related complications than patients treated with urgent-start hemodialysis. In a trial that randomly assigned over 200 patients to urgent-start PD or urgent-start hemodialysis, the composite complication rate was lower in the urgent-start PD group (19 versus 37 percent) [21]. Similar findings have been reported among older adults, a population traditionally considered to fare poorly with self-care modalities such as PD [16,22].

A 2020 Cochrane review of nearly 3000 patients (one trial and 15 observational studies) compared urgent-start PD with conventional PD [23]. With the exception of possible increased risk of dialysate leaks (relative risk 3.90; 95% CI 1.56-9.78), there appeared to be no other major increase in the risk of complications among patients who received urgent-start PD compared with conventional PD. Specifically, there were no definitive differences between urgent-start and conventional PD with regards to the risk of catheter blockage, malposition or readjustment, PD dialysate flow problems, infectious complications, exit-site bleeding, technique survival, or patient survival.

Despite the higher incidence of dialysate leaks observed with urgent-start PD in some studies, there does not appear to be a discernable increase in the risk of adverse patient outcomes or of patient dropout to hemodialysis [24-26]. Most leaks can be managed conservatively without need for replacement of the PD catheter. The risk of leakage can be minimized by appropriate catheter placement techniques. (See "Placement of the peritoneal dialysis catheter".)

CONTRAINDICATIONS — Patients who require emergent dialysis (usually for hyperkalemia, volume overload, or marked uremia) are not good initial candidates for urgent-start peritoneal dialysis (PD), since such patients cannot wait for PD catheter placement. Furthermore, as compared with hemodialysis or continuous kidney replacement therapy (CKRT), it is more difficult to achieve rapid metabolic control with PD. Such patients should be managed with hemodialysis or CKRT utilizing a temporary vascular catheter. Once stabilized, suitable PD candidates may have a PD catheter placed and rapidly transitioned to PD with urgent-start PD protocols.

SETTING UP AN URGENT-START PERITONEAL DIALYSIS PROGRAM — Establishing a successful urgent-start peritoneal dialysis (PD) program requires administrative support and the commitment of multiple disciplines. There are five key elements to a successful program [27]:

●Ability to place peritoneal catheters with 48 hours

●Staff education regarding use of catheter immediately after placement

●Administrative support (inpatient and outpatient settings)

●Identification of appropriate urgent-start PD candidates

●Utilization of protocols in every step of the urgent-start process (from patient selection until ready to discharge home)

Rapid catheter placement — Rapid peritoneal catheter placement is the rate-limiting step in any urgent-start program. If PD catheters cannot be placed as quickly as tunneled hemodialysis catheters, the default pathway for late-referred patients will be hemodialysis.

Peritoneal catheters may be placed percutaneously (typically by interventional radiologists or nephrologists) or laparoscopically (typically by surgeons). Irrespective of the method of catheter placement, there must be a commitment by the surgical team to place catheters within 24 to 48 hours of request and to manage catheter complications in a timely manner. The method of placing the catheter may require modification to minimize the risk of pericatheter leaks [4]. Surgeons should be assured that the medical and nursing team will take specific steps to minimize the risk of early catheter complications despite early use of the catheter.

Staff education — Inpatient and outpatient PD nurses should be familiar with methods that minimize the risk of catheter complications (such as catheter leaks) in patients undergoing urgent-start PD. These methods include the use of low-volume exchanges and having the patient in a recumbent position. Nurses should also be capable of managing early complications, such as catheter leaks. (See "Noninfectious complications of peritoneal dialysis catheters", section on 'Pericatheter leakage'.)

Ideally, there should be more than one nurse available who has sufficient expertise with early-start PD. This is especially important in outpatient facilities, where the urgent-start patient may be dialyzed on-site, while other aspects of the PD program are ongoing.

It is important that center-specific protocols for urgent-start PD be designed with input from the PD staff. If established urgent-start PD programs exist in the geographic area, collaboration should be encouraged. To minimize concern about patient safety, outpatient PD nurses should be assured that only medically stable patients will be dialyzed urgently in the outpatient dialysis clinics.

Administrative support — There must be adequate staffing, space, and equipment to establish an urgent-start PD program. This requires the support of hospital and PD clinic administration. Administrators must be aware of the potential benefits of urgent-start PD. These include decreased vascular catheter-related complications, patient benefits, and the potential for decreased rehospitalization as compared with urgent-start hemodialysis. (See 'Background' above and 'Outcomes' above.)

Hospital administrators must assure adequate surgical staffing, equipment (including catheter kits and peritoneal dialysis supplies), and adequate PD nurse staffing and training. Outpatient administrators must assure adequate space, staffing, and supplies to allow for in-center PD. In outpatient facilities, at least two rooms should be available for PD. This is so that one room may be used for urgent-start patients while the other rooms are used for the usual activities of an outpatient PD clinic (including routine visits of patients maintained on PD and training of patients anticipating routine initiation of PD). A chair that allows a recumbent position should be available to patients on urgent-start PD to minimize increases in intra-abdominal pressure and risk of peritoneal fluid leak.

Identifying appropriate candidates — Identifying the appropriate urgent-start PD candidate increases the chances for successful initiation of dialysis and the probability of long-term technique survival. Appropriate candidates for urgent-start PD include patients who have an urgent indication to start chronic dialysis. The candidate must not have absolute contraindications to chronic PD (severe intraperitoneal adhesions, mental or physical incapacity without an assistant, uncorrectable mechanical defects such as hernias or internal leaks) (see "Placement of the peritoneal dialysis catheter" and "Use of peritoneal dialysis (PD) for the treatment of acute kidney injury (AKI) in adults", section on 'Ideal candidates') or have an emergent need for dialysis.

In addition, patients should not have an emergent indication for dialysis. (See 'Contraindications' above.)

We utilize a bedside predialysis patient questionnaire to evaluate candidacy for chronic peritoneal dialysis. The two main areas evaluated are:

●Social barriers (eg, home status/cleanliness, access to toilet and sink, space for PD supplies, employment status, caregiver support)

●Medical/surgical/psychiatric barriers (eg, functional status, abdominal surgeries, psychiatric, memory issues, vision, hearing or dexterity impairment)

Many of these barriers are not absolute contraindications to PD and thus, if resolved, can allow patients to get onto PD.

Development of protocols — Most successful urgent-start PD programs are protocol driven. As noted above, protocols for urgent-start PD should be designed with input from the PD staff. Examples of urgent-start-specific protocols include the following [28]:

●Initial assessment to evaluate need for immediate PD initiation (table 1)

●Initial urgent-start PD prescription (table 2)

●Post-PD catheter patient orders (table 3)

The initial assessment includes clinical and lab parameters to determine the urgency of PD initiation after placement of the PD catheter. Patients are questioned about signs and symptoms suggesting severe uremia and volume overload (see "Indications for initiation of dialysis in chronic kidney disease", section on 'Indications for initiation of chronic dialysis'). Initial lab work is reviewed, in particular for hyperkalemia. If the evaluation suggests need for immediate dialysis initiation, automated low-volume, recumbent PD is started (table 2).

Prior to catheter placement, orders should include presurgical bathing with antiseptic soap, preoperative antibiotics, and a bowel preparation to minimize bowel distension and risk for postoperative constipation. Postoperatively, strict orders are provided to avoid manipulating catheter dressing (table 3). A bowel regimen should be prescribed postoperatively.

After placement, catheters are immediately tested for patency, functionality, and for the presence of blood with low-volume exchanges (ie, 500 mL). If the effluent is clear and the catheter functions normally, the abdomen is fully drained and left empty until the patient is seen in the dialysis unit for urgent-start PD initiation. If the effluent is blood tinged, low-volume exchanges are continued until the blood clears the abdomen. If the patient is hemodynamically stable, heparin (500 units/liter) is added to minimize the risk for clotting. If the bleeding fails to clear with three or four exchanges, the patient will need further evaluation to rule out internal bleeding (table 3). (See "Noninfectious complications of peritoneal dialysis catheters", section on 'Complications of insertion'.)

INITIAL PRESCRIPTION — The dialysis prescription must be modified from the usual chronic ambulatory peritoneal dialysis (CAPD) or automated peritoneal dialysis (APD) prescription to avoid pericatheter leak and other complications that may result from use of the catheter before the incision is completely healed from surgery and before the patient is trained to perform the dialysis alone.

The initial PD prescription depends on the degree of residual kidney function, patient size (body surface area), and clinical indicators as per the patient evaluation. Initial fill volumes are limited to 750 to 1250 mL, depending on the patient's body surface area (table 2). Time on therapy and number of cycles are determined by the patient's residual kidney function and specific clinical parameters (including signs and symptoms of uremia, electrolyte and acid-base disorders, disorders of mineral metabolism). (See "Indications for initiation of dialysis in chronic kidney disease".)

A typical prescription for a patient who has some residual kidney function is four to six cycles over a five- to eight-hour period. Therapy is usually done on an alternate-day basis in the first two weeks after catheter placement. This allows for alternate dry days, which increase surgical healing. However, if needed, daily therapy can be provided. Strict measures are to be taken to avoid increase in intra-abdominal pressure to avoid leaks. These measures include a bowel regimen for all patients to avoid straining with bowel movement; cough suppressants, if needed; and draining patients when sitting up, eating, or ambulating (table 2).

CLINICAL PATHWAY TO URGENT-START PERITONEAL DIALYSIS — We employ the following clinical pathway for patients undergoing urgent-start peritoneal dialysis (PD) (algorithm 1) [27]:

●Dialysis options should be discussed with all patients. Appropriateness for PD should be assessed.

●Suitable candidates for PD should be referred to an access surgeon or interventional radiologist/nephrologist, who should place a PD catheter within 24 to 48 hours of referral. At the same time, a referral should be placed to a PD clinic that has an established urgent-start PD program. After PD catheter placement, as long as the patient does not have another medical indication to remain hospitalized, the patient can be discharged with follow-up at the designated PD clinic.

●The patient is evaluated for the need for immediate dialysis initiation.

•If immediate dialysis is required, the patient is started on nurse-assisted, low-volume, recumbent, automated intermittent peritoneal dialysis (IPD) or daily automated peritoneal dialysis (APD) [29]. Dialysis is usually performed in an outpatient PD clinic for a period of two to three weeks, until patients are sufficiently trained to perform dialysis at home. However, if the patient has indications to be hospitalized, nurse-assisted low-volume PD can be performed in the inpatient setting until the patient is stable for discharge.

If a cycler is not available, urgent-start PD can be accomplished with low-volume manual exchanges, although care must be taken by nursing staff not to accidentally instill larger-than-intended volume of PD fluid into the peritoneum.

•If there is no indication for immediate dialysis initiation, training can commence. The patient's clinical status is monitored at each visit and lab work obtained at minimum weekly. Dialysis therapy should be started when appropriate.

Among patients who require immediate dialysis, after the first week of nurse-assisted PD, training is initiated on nondialysis days. By the end of the third week, the patients are usually adequately trained to be able to transition to self-care at home.

BARRIERS TO URGENT START — The major barrier to an urgent-start peritoneal dialysis (PD) program is the lack of surgeons or interventionalists (radiologists or nephrologists) who can place a PD catheter within 48 hours.

Local urgent-start PD programs for the outpatient may not available. In such cases, the referring clinician may work with a PD clinic in the area that has adequate staffing, space, and general PD experience to start an urgent-start PD program.

SUMMARY AND RECOMMENDATIONS

●Overview of urgent-start peritoneal dialysis – Urgent-start peritoneal dialysis (PD) is the initiation of PD in patients with newly diagnosed end-stage kidney disease (ESKD) who are not yet on dialysis and who require dialysis initiation less than two weeks after PD catheter placement but do not require emergent dialysis. It is useful because it circumvents the need for temporary hemodialysis. Urgent-start PD may also increase the number of patients who utilize PD for kidney replacement therapy. (See 'Introduction' above and 'Definition' above and 'Background' above.)

●Contraindications to urgent-start PD – Patients who require emergent dialysis (usually for hyperkalemia, volume overload, or marked uremia) are not good initial candidates for urgent-start PD, since such patients cannot wait for PD catheter placement. Such patients should be managed with hemodialysis or continuous kidney replacement therapy (CKRT) utilizing a temporary vascular catheter. Once stabilized, suitable PD candidates may have a PD catheter placed and transition to PD with urgent-start PD. (See 'Contraindications' above.)

●Outcomes – Urgent-start PD appears to be as safe as routine (ie, planned) PD, although there may be an increase in the incidence of peritoneal leaks. It is as safe or safer than urgent-start hemodialysis for appropriate candidates. (See 'Outcomes' above.)

●Starting a program – The rate-limiting step in establishing a successful urgent-start PD program is getting consistent, timely placement of PD catheters (ie, within 48 hours). Other key elements to establishing a successful urgent-start program include sufficient numbers of trained PD nurses, administrative support, and a suitable infrastructure and being able to quickly identify appropriate candidates. Establishing and utilizing protocols for every step of the urgent-start process will increase the chances for a successful program. (See 'Setting up an urgent-start peritoneal dialysis program' above.)

●The initial PD prescription – The initial PD prescription depends on the degree of residual kidney function, patient size (body surface area), and clinical indications for dialysis. Initial fill volumes are limited to 750 to 1250 mL. (See 'Initial prescription' above.)

●Avoidance of dialysate leaks – Strict measures should be taken to avoid increase in intra-abdominal pressure to avoid leaks. These measures include a bowel regimen for all patients to avoid straining with bowel movement; cough suppressants, if needed; and draining patients when sitting up, eating, or ambulating. (See 'Initial prescription' above.)